Corrective Action Plans

Finding 60633 (2022-006)

Significant Deficiency 2022

ND

Reporting Internal Control / Segregation of Duties Special Tests & Provisions

Finding 2022-006 U.S. Department of Agriculture CFDA # 10.565 Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, it was identified that no formal documentation of the review process for CSFP inventory reports existed and that a tested sample contained an error...

Finding 2022-006 U.S. Department of Agriculture CFDA # 10.565 Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, it was identified that no formal documentation of the review process for CSFP inventory reports existed and that a tested sample contained an error. Responsible Individuals: Melissa Sobolik, CEO, David Stachon, CFO Corrective Action Plan: Management will work with staff to create a formal documentation and review process for CSFP inventory reports. This review will be conducted prior to submission and retained for future review. Anticipated Completion Date: March, 2023

View Audit 56189

Finding 60632 (2022-005)

Significant Deficiency 2022

Great Plains Food Bank

ND

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility

Finding 2022-005 U.S. Department of Agriculture CFDA # 10.565, 10.568, 10.569 Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations for the CSFP and Emergency Food Assistance Programs. Two...

Finding 2022-005 U.S. Department of Agriculture CFDA # 10.565, 10.568, 10.569 Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations for the CSFP and Emergency Food Assistance Programs. Two tested samples did not have the proper documentation. Responsible Individuals: Melissa Sobolik, CEO, David Stachon, CFO Corrective Action Plan: The GPFB will ensure all documents for TEFAP and CSFP programs have proper signatures by necessary parties going forward. This will be done as paperwork is completed and retained in the file. Anticipated Completion Date: March, 2023

View Audit 56189

Finding 60631 (2022-004)

Significant Deficiency 2022

Great Plains Food Bank

ND

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-004 U.S. Department of Agriculture CFDA # 10.565, 10.568 Food Distribution Cluster Finding Summary: A lack of internal controls allowed four expense transactions to be allocated to federal programs that did not meet the requirements to be allowable within the grant. Responsible Indi...

Finding 2022-004 U.S. Department of Agriculture CFDA # 10.565, 10.568 Food Distribution Cluster Finding Summary: A lack of internal controls allowed four expense transactions to be allocated to federal programs that did not meet the requirements to be allowable within the grant. Responsible Individuals: Melissa Sobolik, CEO David Stachon, CFO Corrective Action Plan: Accounting staff continue to refine procedures to ensure accurate compliance for both allowable expenses and proper allocation of expenses. All allocated expense accounts will be reviewed before any allocation is made to prevent any unallowable expenses from being allocated. Anticipated Completion Date: On going

View Audit 56189

Finding 60622 (2022-001)

None 2022

Careflite

TX

Reporting Internal Control / Segregation of Duties

12/7/2022 CareFlite Corrective Action Plan Finding: 2022-001 Corrective Action: Controls have been put in place as of December 7, 2022 to ensure reports are run with correct parameters and are reviewed prior to being submitted to granting agency. Contact Information: Dustin Kahler, Contro...

12/7/2022 CareFlite Corrective Action Plan Finding: 2022-001 Corrective Action: Controls have been put in place as of December 7, 2022 to ensure reports are run with correct parameters and are reviewed prior to being submitted to granting agency. Contact Information: Dustin Kahler, Controller 3110 S. Great Southwest Parkway Grand Prairie, TX 75052

View Audit 49812

Finding 60547 (2022-002)

Significant Deficiency 2022

Lake Michigan College

MI

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-002 ALN, Federal Agency, and Program Name- Education Stabilization Fund-Higher Education Emergency Relief Fund ALN 84.425 Condition: The College did not submit HEERF student quarterly reports timely and reported inaccurate information in certain line items within the 2021 HEERF...

Finding Number: 2022-002 ALN, Federal Agency, and Program Name- Education Stabilization Fund-Higher Education Emergency Relief Fund ALN 84.425 Condition: The College did not submit HEERF student quarterly reports timely and reported inaccurate information in certain line items within the 2021 HEERF annual report. Planned Corrective Action: The delay in posting the quarterly reports online was an oversight but they were properly submitted to the US Department of Education timely. The annual reports were corrected and submitted as of 3/16/23 and going forward we will ensure there is a review of data before it is submitted or posted. Contact person responsible for corrective action: Nicole Hatter Anticipated Completion Date: 3/16/2023

View Audit 56183

Finding 60537 (2022-005)

Significant Deficiency 2022

Madison Commuity Unit School District #12

IL

Reporting Internal Control / Segregation of Duties

THE DISTRICT WILL TAKE THE NECESSARY STEPS TO FILE ALL QUARTERLY EXPENDITURE REPORTS ON TIME IN THE FUTURE.

View Audit 60954

Finding 60474 (2022-003)

Material Weakness 2022

Amberwell Atchison Association D/b/a Amberwell Atchison

KS

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The terms...

Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 4 reporting required an organization to illustrate how PRF and ARP funds received were used. An organization was allowed to include eligible expenditures from January 1, 2020 through December 31, 2022 depending on the period reporting. Condition: During the process of identifying expenses that were incurred to prevent, prepare for, or respond to the coronavirus pandemic, management properly incurred and reported reflected expenses within the period of availability; however, the quarterly expenses reported on the portal submission did not reflect the actual quarter in which the expenses were incurred. Planned Corrective Action: Management will continue to refine its processes to more diligently review expenditures to ensure accurate reporting of expenses by quarter in future reporting. Planned Completion Date: December 31, 2023 Person Responsible: Chase Dudzinski, Chief Financial Officer

View Audit 56025

Finding 60408 (2022-001)

Material Weakness 2022

City of Marion

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303 § 200.328

FINDING 2022-001 Material Weakness - Reporting Contact Person Responsible for Corrective Action: Julie Flores Contact Phone Number: 765-382-3779 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The Controller?s Office will send the monthly appropriation report...

FINDING 2022-001 Material Weakness - Reporting Contact Person Responsible for Corrective Action: Julie Flores Contact Phone Number: 765-382-3779 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The Controller?s Office will send the monthly appropriation reports for transportation to the Administrative Assistant (AA) and to the Transportation Manager to review and reconcile. After the monthly report has been reconciled by the transportation Administrative Assistant, it will be initial and dated by the AA, the work will be forwarded to the grant administrator, transportation manager and controller?s office. The Controller?s Office will review to ensure accurate information was forwarded to the grant administrator. These changes will be reflected in the City of Marion?s Internal Control Policy. Anticipation Completion Date: 09/01/23

View Audit 50527

Finding 60401 (2022-002)

None 2022

Windham Housing Corporation

OH

Cash Management HUD Housing Programs Internal Control / Segregation of Duties

2. Current Findings on the Schedule of Finding, Questioned Cost and Recommendation b. Finding 2022-002. Residual Receipts Surplus cash in the amount of $77,939 was not deposited into the residual receipts account within 60 days after the end of the fiscal year. Surplus cash be deposited into t...

2. Current Findings on the Schedule of Finding, Questioned Cost and Recommendation b. Finding 2022-002. Residual Receipts Surplus cash in the amount of $77,939 was not deposited into the residual receipts account within 60 days after the end of the fiscal year. Surplus cash be deposited into the residual receipts account, within 60 days after the end of the fiscal year. (1) Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor?s recommendation that surplus cash should be deposited into the residual receipts account within 60 days after the end of the fiscal year. (2) Actions Taken on the Finding. Payment in process.

View Audit 49802

Finding 60391 (2022-012)

Significant Deficiency 2022

County of Orange, California

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.01 § 200.303

Program: COVID-19 Emergency Rental Assistance Program Federal Financial Assistance Listing Number: 21.023 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control and Instance of Noncomplianc...

Program: COVID-19 Emergency Rental Assistance Program Federal Financial Assistance Listing Number: 21.023 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.01 of the Uniform Guidance states that the County may report charges on a cash or accrual basis, as long as the methodology is disclosed and consistently applied. Condition: During our testing of the HCA?s provisions for reporting requirements, we noted the following instance where reports were prepared on the cash basis, but reports indicated that the costs were reported on the accrual basis of accounting: ? Two (2) out of the three (3) reports for the HCA. Corrective action of prior year finding was implemented mid-year. Cause: The HCA department reported amounts on cash basis, but the form identified the basis for the report as ?accrual?. The HCA department review process and certification of the report did not identify the discrepancy. Effect: The County?s control was not consistently followed, which applies the basis of accounting on a consistent basis. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of three (3) reports were selected for report testing. Repeat Finding from Prior Years: Yes, Finding 2021-005. Recommendation: We recommend the HCA adhere to their policies and apply the same basis of accounting on a consistent basis for the program. Management Response and Corrective Action: Health Care Agency: 1. Person Responsible: Cindy Wong, HCA Accounting Services Division Manager 2. Corrective action plan: Once identified during prior year?s Single Audit, HCA Accounting has ensured the appropriate basis of accounting is reported correctly and applied consistently for the ERAP program. 3. Anticipated Implementation date: Fully Implemented

View Audit 56545

Finding 60368 (2022-011)

Significant Deficiency 2022

County of Orange, California

CA

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Public Health Award No. and Year: 2022 Compliance Requirements: Eligibility Type of Finding: Significant Deficiency i...

Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Public Health Award No. and Year: 2022 Compliance Requirements: Eligibility Type of Finding: Significant Deficiency in Internal Control Criteria: Title 42 Chapter IV Subchapter C Part 425 Subpart J Section 435.907, Application, states that the agency must accept an application from the applicant, an adult who is in the applicant's household, as defined in ? 435.603(f), or family, as defined in section 36B(d)(1) of the Code, an authorized representative, or if the applicant is a minor or incapacitated, someone acting responsibly for the applicant, and any documentation required to establish eligibility which includes via the internet Web site, by telephone, via mail, in person, and through other commonly available electronic means. Condition: During our testing of the SSA?s provisions for eligibility requirements, we noted for three (3) of sixty (60) samples the department did not retain the participant?s application, which is part of the County?s process and internal control. Cause: The SSA department did not ensure case workers were following the department?s policies and procedures relating to the eligibility determination process. Effect: The County?s control was not consistently followed, which requires case workers to retain the participant?s application. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: Non-statistical sample of sixty (60) out of two hundred ninety-four thousand and one hundred sixteen (294,116) participants were selected for eligibility testing. The condition above was identified during our testwork of the SSA?s internal controls over eligibility. Repeat Finding from Prior Years: No. Recommendation: We recommend the SSA department adhere to their policies and ensure case workers retain participant applications. Management Response and Corrective Action: Social Services Agency: 1. Person Responsible: Cristina Espinoza, Administrative Manager I, Assistance Programs, Policy and Operations Team 2. Corrective action plan: Department will provide Single Audit findings in a mandatory Program Summary meeting that all staff will attend. At the meeting, department will address the findings in detail and remind staff who administer Medi-Cal to: ? Ensure case documentation such as: initial application and supporting verification are imaged ? Enter case comments that support case actions The department will also continue to have the Quality Assurance team complete case reviews to ensure eligibility workers are following policies and procedures in completing accurate eligibility determinations. 3. Anticipated Implementation date: April 2023

View Audit 56545

Finding 60351 (2022-008)

Significant Deficiency 2022

County of Orange, California

CA

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Social Services Award No. and Year: 2022 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Inte...

Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Social Services Award No. and Year: 2022 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: During our testing of the Social Services Agency?s (SSA) provisions for reporting requirements, we noted the following instance where reports were prepared, reviewed, and approved by the same individual: ? Two (2) of four (4) reports for the SSA Cause: The SSA department did not have a segregation of duties over the preparation and review and approval of performance reports. Effect: The County?s control was not consistently followed, which requires reports to be reviewed and approved by a separate individual. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A non-statistical of four (4) out of twelve (12) reports were selected for reporting testing from SSA. The condition above was identified during our testwork of the SSA?s internal controls over reporting. Repeat Finding from Prior Years: No. Recommendation: We recommend the SSA adhere to their policies and ensure segregation of duties over the preparation and review and approval of performance reports. Management Response and Corrective Action: Social Services Agency: 1. Person Responsible: Silvia Fuller, Administrative Manager II, Research 2. Corrective action plan: SSA has normally adhered to policy of segregation of duties over the preparation and review and approval of performance reports. However, during 2021 the assignment of the CA 237 FC report fell to one individual due to staff vacancies caused by the COVID Pandemic. Effective August 2022, the report has been assigned to the Research Unit which is following and adhering to the policy of segregation of duties. 3. Anticipated Implementation date: Fully implemented as of August 2022

View Audit 56545

Finding 60346 (2022-007)

Significant Deficiency 2022

County of Orange, California

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.334

Program: Immunization Cooperative Agreements Federal Financial Assistance Listing Number: 93.268 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Public Health Award No. and Year: 17-10336 A02 and 2021 Compliance Requirements: Reporting Type of ...

Program: Immunization Cooperative Agreements Federal Financial Assistance Listing Number: 93.268 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Public Health Award No. and Year: 17-10336 A02 and 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.334, Retention requirements for records, states that financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a federal award must be retained for a period of three years from the date of submission of the final expenditure report, or, for Federal awards that are renewed quarterly or annually, from the date of submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. Condition: During our testing of the HCA?s provisions for reporting requirements, we noted the following instances for two (2) out of two (2) reports: ? The performance reports were not reviewed or approved prior to submission to the State. ? The department did not retain any supporting documents for the performance reports. Cause: The HCA department personnel prepared program required performance reports and submitted to the State without retaining evidence that the reports were reviewed and approved by a separate individual prior to submission. The HCA department did not retain any supporting documents for the performance reports submitted. Effect: The County?s control was not consistently followed, which requires reports to be reviewed and approved by a separate individual prior to submission to the State. Additionally, the HCA department did not adhere to their policies and procedures in place requiring record retention of supporting documentation. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of two (2) performance reports were selected for report testing for the Immunization Cooperative Agreements program. Repeat Finding from Prior Years: No. Recommendation: We recommend the HCA adhere to their policies and ensure the review and approval of reports are clearly documented prior to the report?s submission and adhere to their policies of record retention of supporting documents for the performance reports submitted to the State. Management Response and Corrective Action: Health Care Agency: 1. Person Responsible: Joshua Jacobs, HCA Public Health Services - Communicable Disease Control Division Director 2. Corrective action plan: HCA Public Health Services Communicable Disease Control Division will ensure retention of proper documentation supporting the performance reports and substantiating the review/approval prior to report submission to the State for the Immunization Cooperative Agreement. 3. Anticipated Implementation date: March 27, 2023

View Audit 56545

Finding 60342 (2022-010)

Significant Deficiency 2022

County of Orange, California

CA

Special Tests & Provisions Eligibility Reporting

Program: Supplemental Nutrition Assistance Program (SNAP) Cluster Federal Financial Assistance Listing Number: 10.561 Federal Grantor: U.S. Department of Agriculture Passed-Through: California Department of Social Services Award No. and Year: 217CACA4S2514, 227CACA4S2514, 217CACA4Q7503, 227CACA4Q750...

Program: Supplemental Nutrition Assistance Program (SNAP) Cluster Federal Financial Assistance Listing Number: 10.561 Federal Grantor: U.S. Department of Agriculture Passed-Through: California Department of Social Services Award No. and Year: 217CACA4S2514, 227CACA4S2514, 217CACA4Q7503, 227CACA4Q7503, 217CACA4S2519, 227CACA4S2519, 217CACA4S2520, 227CACA4S2520, 217CACA5S9018, 217CACA6F1003, 227CACA7F1003 and 2022 Compliance Requirements: Special Tests and Provisions Type of Finding: Significant Deficiency in Internal Control Criteria: 7 CFR sections 272.10 and 277.18 require State agencies to automate their SNAP operations and computerize their systems for obtaining, maintaining, utilizing, and transmitting information concerning SNAP. This includes: (1) accurately and completely processing and storing all case file information for eligibility determination and benefit calculation; (2) providing an automatic cutoff of households at the end of their certification period unless recertified; and (3) generating data necessary to meet federal issuance and reconciliation reporting requirements. Condition: In establishing a new case, the client is certified to receive benefits for a one-year period (certification period). The intake and certification process require that information on the CF-37 and SAWS 2 be obtained to determine eligibility and assist in the benefit calculation. Further, prior to case worker approval of benefits, the Income Eligibility Verification System (IEVS) report is required to be processed in certain circumstances. During our testing of the SSA department?s provisions for special tests and provisions requirements relating to ADP System for SNAP, we noted the following instances: ? For thirteen (13) of forty (40) participants selected for testing, there was no evidence that a case worker reviewed and certified the participants IEVS report. ? For three (3) of forty (40) participants selected for testing, the income verification document used in the benefit calculation was not retained by the department. Cause: The condition is primarily caused by the SSA department not following policies and procedures in place to ensure the eligibility case files contain documentation to support eligibility and benefit calculations. Effect: Case data may not be current or accurate in the case file or the system, which could lead to initial and continued eligibility errors, inaccurate benefit calculations, and benefit overpayments. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A non-statistical sample of forty (40) out of one hundred eleven thousand and fifty-one (111,051) participants were selected for special tests and provisions relating to ADP System for SNAP. The condition above was identified during our testwork of the SSA?s internal controls over special tests and provisions. Repeat Finding from Prior Years: No Recommendation: We recommend the County strengthen its established policies and procedures with regard to initial and ongoing eligibility determination, required documentation and verifications, maintenance of participant files, and ensure that policies and procedures are strictly adhered to by County personnel. Management Response and Corrective Action: Social Services Agency: 1. Person Responsible: Cristina Espinoza, Administrative Manager I, Assistance Programs, Operations and Policy Team 2. Corrective action plan: Department will provide Single Audit findings in a mandatory Program Summary meeting that all staff will attend. At the meeting, department will address the findings in detail and remind staff who administer CalFresh to: ? Review and process IEVS reports timely and accurately ? Ensure case verifications are imaged and documented in case comments to support case action ? Review the budget wrap-up screen thoroughly for every case The department will also continue to have the Quality Assurance team complete case reviews to ensure eligibility workers are following policies and procedures in completing accurate eligibility determinations. 3. Anticipated Implementation date: April 2023

View Audit 56545

Finding 60339 (2022-003)

Significant Deficiency 2022

City of Fort Walton Beach, Florida

FL

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Management concurs and will revisit policies and procedures relating to grant administration to ensure that supervisory review procedures are performed.

View Audit 56332

Finding 60335 (2022-001)

Significant Deficiency 2022

Somerset-Berkley Regional School District

MA

School Nutrition Programs Significant Deficiency Internal Control / Segregation of Duties § 200.430

Condition: Time records provided to support salaries and wages charged to the school lunch revolving fund were not approved by supervisory personnel. Corrective Action Planned: The District has implemented procedures utilizing time clock systems. The Administrative Assistant assigned to the Food Ser...

Condition: Time records provided to support salaries and wages charged to the school lunch revolving fund were not approved by supervisory personnel. Corrective Action Planned: The District has implemented procedures utilizing time clock systems. The Administrative Assistant assigned to the Food Service Program reviews the system report to verify hours worked and absences. The report is then printed, reviewed and signed-off by the Food Service Manager prior to submitting the wage/hourly report to payroll. Anticipated Completion Date: January 2023 Contact: Ronald D. Tarro, Director of Business & Finance

View Audit 54720

Finding 60332 (2022-002)

Material Weakness 2022

Loma Linda University

CA

Reporting Internal Control / Segregation of Duties

2022-002 ? Internal control deficiency and noncompliance over amounts reported in the Schedule of Expenditures of Federal Awards (SEFA) During testing over the SEFA, an incorrect balance was reported on the SEFA as management included $235,330 in out-of-period expenditures that related to June 30, ...

2022-002 ? Internal control deficiency and noncompliance over amounts reported in the Schedule of Expenditures of Federal Awards (SEFA) During testing over the SEFA, an incorrect balance was reported on the SEFA as management included $235,330 in out-of-period expenditures that related to June 30, 2021, and did not include $306,646 in expenditures that related to June 30, 2022. The expenditures that are required to be on the SEFA should be based on the service period of July 1, 2021 to June 30, 2022. Management?s internal control over review of the SEFA did not identify this incorrect reporting. The amount reported in the SEFA was subsequently corrected and the corrected amount is reflected in the data collection form. Management Response and Action Plan: Out-of-period expenditures were not captured in the financial records of the related fiscal year. An additional review process of the SEFA will be implemented and performed by management to ensure the SEFA contains complete and accurate reporting of expenditures. Completeness analysis will consider not only the PPM subledger but the general ledger and communication from the principal investigators regarding unrecorded but incurred expenditures. Evidence of the review will be documented and retained. Responsible Person: AVP Research Operations and Director of Post Award Target Date: June 2023 (Anticipated)

View Audit 54839

Finding 60323 (2022-001)

Significant Deficiency 2022

Village Cooperative of Fergus Falls

MN

Internal Control / Segregation of Duties Significant Deficiency

The Board of Directors is and will remain involved in the financial affairs of the Cooperative.

View Audit 55618

Finding 60320 (2022-001)

Significant Deficiency 2022

Youth Services Network, Inc.

IL

Internal Control / Segregation of Duties

Youth Services Network, Inc. has implemented several compensating controls but simply cannot justify the expense of hiring additional staff to reach the standard of segregation of duties suggested.

View Audit 55612

Finding 60273 (2022-007)

Material Weakness 2022

City of Detroit, Michigan

MI

Subrecipient Monitoring Eligibility Material Weakness § 200.303

Finding Number: 2022-007 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Housing and Urban Development, Housing Opportunities for Persons With Aids (HOPWA) and COVID-19 HOPWA Condition: Original Finding Description: In conjunction with eligibility testing, instances of...

Finding Number: 2022-007 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Housing and Urban Development, Housing Opportunities for Persons With Aids (HOPWA) and COVID-19 HOPWA Condition: Original Finding Description: In conjunction with eligibility testing, instances of noncompliance specific to the rental assistance calculation were identified. Contact Person Responsible for Corrective Action: Denise Fair and Angelique Tomsic Anticipated completion date: July 2023 Planned Corrective Action: In FY23, the City implemented a review of 100% of clients who received subsidy services. The intensive review is being performed to help ensure all required documents are saved and accurate. A corrective action plan will be documented and further reviews put in place to help ensure compliance and consistency for all rental calculations. The city will also continue to work with its contractor on process improvements. In addition, as part of the AFCAP process, the City will work with the department to perform internal reviews to help ensure processes are being followed

View Audit 49776

Finding 60260 (2022-006)

Material Weakness 2022

City of Detroit, Michigan

MI

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding Number: 2022-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City of Detroit did not have adequate controls in place to ex...

Finding Number: 2022-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City of Detroit did not have adequate controls in place to exercise its oversight responsibility of eligibility determinations that were performed by a contractor for the program. Contact Person Responsible for Corrective Action: Denise Fair Anticipated completion date: July 2023 Planned Corrective Action: The City will implement controls to ensure that Health Department provides oversight of the contractor and the participant eligibility process. The Health Department has hired a WIC Program Director who will monitor participant eligibility compliance and ensure that eligibility policies and procedures are maintained and followed. Through the AFCAP project process, the City will also review the contract in detail to help ensure full compliance

View Audit 49776

Finding 60259 (2022-004)

Material Weakness 2022

Logan Health

MT

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: The operations of HealthCenter Northwest, LLC (HC) were consolidated into Kalispell Regional Medical Center d/b/a Logan H...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: The operations of HealthCenter Northwest, LLC (HC) were consolidated into Kalispell Regional Medical Center d/b/a Logan Health Medical Center (LHMC) as of December 31, 2020. When LHMC calculated their lost revenues, they included HC's revenue for both 2020 and 2021 instead of only the 2021 information. This resulted in LHMC reporting higher lost revenue than the detailed reports supported in Period 1. This also affected the lost revenues reported in Period 2 for LHMC. HC filed its own report for Period 1, which included their revenues for 2019 and 2020. Zeros were entered for 2021, which resulted in reporting higher lost revenues than the detailed reports supported in Period 1. Responsible Individuals: Craig Lambrecht, CEO and Cole Turner, CFO. Corrective Action Plan: The lost revenue calculation will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal will be updated in future periods. Anticipated Completion Date: 3/31/2023

View Audit 49773

Finding 60258 (2022-003)

Material Weakness 2022

Logan Health

MT

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: In some of the quarters for certain entities, it was noted that bad debt expenses were higher than revenues, creating a n...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: In some of the quarters for certain entities, it was noted that bad debt expenses were higher than revenues, creating a negative revenue for the quarter. As the HHS reporting portal would not allow negative amounts to be entered, a zero was entered into the HHS reporting portal. These negative amounts should have been offset to other quarters or other revenue line items, but were not, which resulted in higher revenue amounts being reported than the detailed reports supported. Responsible Individuals: Craig Lambrecht, CEO, and Cole Turner, CFO Corrective Action Plan: The lost revenue calculation for these three locations will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal will be updated in future periods. Anticipated Completion Date: 3/31/2023

View Audit 49773

Finding 60100 (2022-002)

Significant Deficiency 2022

Marshall University Research Corporation

WV

Questioned Costs Subrecipient Monitoring Significant Deficiency

Department of Education, National Science Foundation, Department of Health and Human Services 2022-002 Federal program title: Research & Development Cluster, IDEA Cluster, Opioid STR Federal Assistance Listing Number: 47.074, 84.027, 93.279, 93.788 Condition: Marshall University's indirect cost rate...

Department of Education, National Science Foundation, Department of Health and Human Services 2022-002 Federal program title: Research & Development Cluster, IDEA Cluster, Opioid STR Federal Assistance Listing Number: 47.074, 84.027, 93.279, 93.788 Condition: Marshall University's indirect cost rate agreement contains percentages to be applied to direct costs to claim as indirect costs and fringe benefit rates that are to be applied to salaries and wages of employees charged to federal grants. During testing it was noted that for the period of April 1, 2022 to June 30, 2022, an incorrect indirect cost rate percentage and fringe rate was used to calculate indirect costs charged to federal grants. Recommendation: MURC should implement a control to establish an ongoing review process of the fringe benefit rates being charged to grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding . Action taken in response to finding : MURC will review all Marshall University payroll reimbursement requests from all MURC grants to ensure the fringe benefit rates applied by the University are the correct rates for the fiscal year in which the salary expenses occur. Name(s) of the contact person(s) responsible for corrective action: Jennifer Wood and Rebekah Duke Planned completion date for corrective action plan: September 30, 2022 If the US Department of Health and Human Services has questions regarding this plan, please call Jennifer Wood at 304-696-2829.

View Audit 54850 Questioned Costs: $1

Finding 60099 (2022-003)

Material Weakness 2022

Dekalb County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action: Susan Sleeper Contact Phone Number: 260-925-2362 Views of Responsible Official: I concur with the finding. Description of Corrective Action Plan: New Internal Controls will be implemented, with review of the COIVD-19 annual report pr...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Susan Sleeper Contact Phone Number: 260-925-2362 Views of Responsible Official: I concur with the finding. Description of Corrective Action Plan: New Internal Controls will be implemented, with review of the COIVD-19 annual report prior to submission with email correspondence kept as documentation. Anticipated Completion Date: 06/30/2023

View Audit 54438

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